About comorbidity and case formulation

Veterans commonly present with comorbid disorders and complex needs that require careful treatment planning. For example, up to 90 per cent of veterans with posttraumatic stress disorder (PTSD) will meet criteria for another mental health problem. More complex presentations also require ongoing negotiation with presenting veterans around treatment goals to ensure that underlying problems likely to hinder recovery are addressed. This chapter provides general guidance on case formulation and treatment sequencing for complex clients. While there is some evidence about treatment sequencing, many of the principles presented here are based on clinical opinion, rather than empirical evidence, and need to be applied judiciously by practitioners using their own independent judgment.

Using case formulation to understand complex veteran presentations

Case formulation assists in focussing on presenting problems that are likely to have the most impact on veterans’ recovery and helps set priorities for treatment. There are a number of reasons for systematically and collaboratively developing a case formulation for veterans with complex needs. First and foremost, if a veteran presents with two or more diagnoses, using a diagnostic approach to guide treatment does not help sequence treatment.

In addition, it may be difficult for veterans with long standing comorbid conditions to understand how their mental health problems are maintained and to identify counselling goals that will have a meaningful impact on their recovery. For example, it is not unusual for veterans with chronic PTSD, alcohol dependence and depression to present to counselling with a goal to manage relationship problems. In this instance, avoidance symptoms associated with PTSD, low energy associated with depression, and reluctance to address alcohol problems may mean that the veteran has little awareness or motivation to address underlying problems contributing to relationship difficulties.

Finally, because complex problems often lead to ongoing crises and elevated risks, therapists sometimes focus on crises that emerge during the course of counselling and can be distracted from addressing underlying problems that maintain the client’s presentation.

There are a number of definitions and approaches to case formulation. A commonly accepted definition of case formulation is, “a hypothesis that relates all of the presenting complaints to one another, explains why these difficulties have developed and provides predictions about the patient’s condition” (Wolpe &Turkat, 1985). In other words, case formulation brings together all the information gathered during assessment to develop a working hypothesis that explains how a veteran’s presenting problems have developed and are being maintained (Persons, 2005). It also includes a description of factors that influence and help predict recovery, including protective factors such as social connections and the veteran’s strengths.

In conclusion, case formulation goes beyond summarising information gathered during assessment and provides an explanatory story that is used to focus treatment. The case formulation is used to develop a treatment plan that tackles factors that maintain presenting problems and takes into account factors that may hinder or promote change for the veteran. Because case formulation is a working hypothesis, it involves an ongoing review process throughout counselling where the formulation is tested on a regular basis and adjusted if necessary.

Elements of case formulation

A widely used case formulation model is presented below. This model can be easily adapted to fit in with most treatment approaches or orientations, taking into account factors that lead to and perpetuate presenting issues as well as the client’s vulnerabilities and strengths. A case formulation includes the following elements (see Appendix K for a suggested one page template):

presenting problems

factors that cause the individual to be vulnerable to the development of these problems (vulnerabilities)

factors that trigger the onset of the presenting problems (triggers)

factors that might be barriers or supports for change (positive and negativeprognostic indicators).

The case formulation culminates in the following element:

a hypothesis about the relationship between presenting problems and what maintains them (maintaining factors).

In order to be a useful tool, a case formulation needs to move beyond describing or listing the above factors. It should describe the relationships between these factors and provide a coherent story about the way the veteran is presenting in counselling. There is a free online DVA course on Case Formulation and Treatment Planning available here.

A good case formulation includes and informs a client’s expectations about treatment and can help collaboratively develop goals for therapy. Although the evidence about the impact of a collaborative approach to case formulation on the treatment alliance is inconclusive at present (Rainforth & Laurenson, 2013; Kuyken, Fothergill, Musa, & Chadwick, 2005), it is considered good practice to involve the client in the process as it helps shape their goals for therapy. As discussed earlier, this may be particularly important for clients presenting with complex issues as it may help them understand the importance of addressing underlying problems in order to recover.

A collaborative approach to case formulation also allows the clinician and veteran to discuss factors that maintain current problems, discuss progress and revise treatment goals throughout treatment.

What makes a good case formulation?

For a case formulation to be useful, it needs to quickly and easily lead both therapist and veteran to what needs to be prioritised in a treatment plan. A case formulation is principally a tool to ensure that treatment is targeted to what is most likely going to lead to change for the veteran. It also needs to have the right balance of information and be brief so it can guide the planning and review of treatment effectively. Too much information can lead to a lack of clarity. In addition, it is important that the hypotheses about what leads to, and maintains, presenting problems are informed as much as possible by current evidence.

Lastly, a case formulation is most effective if it explains relationships between presenting problems, vulnerabilities, protective and maintaining factors and triggers. There is evidence that many clinicians use case formulation to summarise assessment information rather than to integrate it into a coherent story that leads to a hypothesis about what maintains clients’ presenting problems (Kuyken, Fothergill, Musa, & Chadwick, 2005). Examples of brief case formulations that explain rather than just describe a client’s presenting problems are provided below.

A DVD with three case studies is included at the back of this book. An example of a case formulation for all three cases is outlined below.

Ron: 62 year old Vietnam veteran

Ron has PTSD and a long established pattern of dependent drinking, consuming between 10-20 standard drinks per day. He also uses high amounts of codeine to manage the chronic pain he experiences in relation to a hip injury sustained in combat. He has very high levels of social anxiety, has experienced panic attacks and spends much of his time at home. Ron and his wife have little interaction but no intention to separate and he has difficulty getting along with his adult children. He has mentioned that he has difficulty remembering things that he feels he should remember. He now gets easily frustrated when trying to complete tasks in his workshop and around the home.

Case formulation in brief - Hypothesis about how main presenting problems are maintained

There are a number of working hypotheses about Ron’s presenting problems. Most importantly, avoidance seems to be the way Ron tends to deal with his problems and this avoidance seems to be perpetuating Ron’s re-experiencing of traumatic events, social anxiety, substance use and social withdrawal. As part of this avoidant pattern, long standing alcohol dependence seems to be a significant contributor to psychological distress and disengagement from others. It may also have led to cognitive decline, which in turn may impact on levels of distress and capacity to change. Chronic pain may also be contributing to Ron’s distress, PTSD symptoms, avoidance and substance use. Finally, it could be that the lack of treatment goals and the long-term failure to address and treat Ron’s PTSD could be leading to low motivation, increased avoidance and substance use.

Predisposing factors - vulnerabilities

In Vietnam, Ron’s involvement in both platoon and civilian deaths led to the development of PTSD.

Precipitating factors - triggers to presenting problems

Ron has experienced PTSD symptoms for a number of years and it is likely that his alcohol dependence and social anxiety stem from a desire to reduce some of these symptoms. His need to avoid distress – whether caused by reminders of traumatic events, pain, or social anxiety – triggers drinking, potential codeine misuse and social withdrawal. Pain may also indirectly trigger substance use as it may act as a reminder of Ron’s time in Vietnam, a time he wishes not to think about. Given the amount of alcohol and codeine consumed by Ron, cravings and/or withdrawal symptoms may also be present and lead to increased substance use. Ron’s excessive drinking may have led to his recent difficulty remembering things and his increased frustration and irritability. Pain and anxiety might also be contributing factors to his memory problems.

Prognostic indicators - barriers or supports for change

A number of factors would indicate that Ron can engage in changing his behaviour and outlook. He has reduced his alcohol consumption and has some insight into the negative effects of alcohol on his life. However, Ron’s motivation to change is limited and he has consistently avoided talking about his trauma. In addition, he appears to have poor expectations of the outcomes of treatment. While the fact that Ron is in a relationship may assist with his recovery, it is evident that this relationship is distant.

Perpetuating factors - what maintains the presenting problems

Ron’s PTSD and social anxiety are perpetuated by the prolonged and pervasive avoidance of emotional distress. He avoids distress by using alcohol, withdrawing from social situations and potentially, by misusing codeine. He has also avoided having surgery on his hip although it causes him increasing pain.

Tim: 28 year old, veteran from Afghanistan

Tim has been diagnosed with PTSD. He binge drinks and uses cannabis on a daily basis. He also occasionally takes methamphetamine whilst at parties. Tim has intermittent bouts of extremely low mood associated with suicidal ideation. Angry outbursts are common; on several occasions he has hit his girlfriend, he has punched walls and he has been involved in a few fights outside nightclubs when intoxicated.

Case formulation in brief - Hypothesis about how main presenting problems are maintained

Two main issues seem to be contributing to Tim’s current presentation: his need to avoid thoughts and feelings related to traumatic events in Afghanistan and difficulties with regulating emotions. Tim’s inability to manage emotions and need to shut out memories of traumatic events lead to substance abuse and impulsive destructive behaviours which in turn lead to feelings of self-hate and hopelessness. These feelings contribute to depression and suicidal ideation which in turn increase the likelihood of substance abuse. Tim’s inability to self-regulate and his need to be in control also contribute to domestic violence.

Predisposing factors - vulnerabilities

A number of factors caused Tim to be vulnerable to the development of PTSD, substance abuse, depression and anger. He has witnessed multiple deaths whilst serving in Afghanistan and witnessed the traumatic and violent death of a friend whilst deployed. In addition, Tim has described being “belted” by his father when he was a child.

Precipitating factors - Triggers to presenting problems

Tim states that he wakes in the morning with low mood, stating that he “hates himself”. He drinks alcohol and uses cannabis to assist with his mood but states that this makes him feel bad about himself and worsens his mood in the longer term. Tim also feels overwhelmingly angry, helpless and scared when he is reminded of events in Afghanistan and tries to shut these emotions out by using cannabis or alcohol. Tim’s suicidal ideation and risk taking (such as fights) seem to be triggered by feelings of self-hatred and a sense of hopelessness that follow a bout of drinking. Tim’s verbal abuse and physical violence towards his partner seems to be the result of a need to be in control and is triggered by events such as her being out of contact.

Prognostic indicators - barriers or supports for change

Tim was given an ultimatum by his partner, Kim, to attend therapy to ensure the longevity of their relationship. While Tim seems to be willingly engaging in the process, he faces a number of barriers to change, most importantly his high levels of alcohol and substance abuse. In addition, Tim presents with low motivation to change, is unsure about what he can get out of therapy and is fearful of talking about his experiences in Afghanistan.

Perpetuating factors - what maintains the presenting problems

Tim’s PTSD is perpetuated by the pervasive avoidance of any reminders of the event. Tim’s attempts to avoid and shut out any thoughts of Afghanistan lead to increased intrusive PTSD symptoms such as nightmares, as well as alcohol and cannabis abuse. Increased alcohol and substance use contributes to Tim’s depressive symptoms. Given Tim’s exposure to childhood abuse and his impulsive behaviour, it is likely that his aggression, risk taking and substance use are maintained by an inability to regulate his emotions. This, together with a need to be in control of his partner, would perpetuate his verbal and physical abuse.

Lisa, 32 years, ex-peacekeeper in East Timor

Lisa served in East Timor when she was 23 years old. She has presented for help in relation to poor sleep patterns. When she lies awake at night she ruminates on her experiences in East Timor and sometimes has nightmares. She is misusing sleeping tablets prescribed by her GP. She is experiencing low mood, a loss of interest in activities and has poor energy levels. She also may be at risk of self-harm, stating that “sometimes it is all too much”. She is being “performance managed” by her supervisor because of difficulties in concentrating at work, and frequent absenteeism.

Case formulation in brief - Hypothesis about how main presenting problems are maintained

Lisa’s rumination about events that she witnessed in East Timor, coupled with her overuse of sleep medication both appear to be contributing to Lisa’s poor sleep patterns, anxiety and low mood. These in turn have contributed to Lisa withdrawing from social relationships and activities that she used to enjoy. The lack of pleasurable activities and social withdrawal act to maintain her low mood and substance use problems. Lisa’s low mood and fatigue are likely to be impeding her ability to work effectively. Given Lisa’s high standards, her difficulties at work are likely to cause her anxiety which has led to her increased absenteeism and, in turn, contribute to Lisa’s low mood.

Predisposing factors - vulnerabilities

Lisa sets very high standards for herself. She believes that she should be in control and that it is her responsibility to perform well. These beliefs may have made Lisa vulnerable to self-recrimination and depression when faced with a situation in East Timor where she was not in control and unable to deliver help as she would have liked.

Precipitating factors - triggers to presenting problems

Lisa’s misuse of sleeping tablets is triggered by her anxiety and low mood. Given that Lisa is building a tolerance to sleep medications, it is possible that worry about not being able to contain her anxiety or cravings are contributing to her anxiety and increased medication use. Negative ruminations about East Timor have led to sleepless nights and low mood. Her reduced role at work and difficulties managing tasks exacerbate self-recrimination and criticism which contribute to her low mood and anxiety. These in turn have led to social isolation and could increase her risk of suicidal ideation and self-harm.

Prognostic indicators - barriers or supports for change

A number of factors may help Lisa in her recovery. Although she is currently socially isolated, Lisa used to have a close relationship with her mother and her sister, relationships which are still important to her. Lisa did not want to attend therapy but had enough insight and motivation to attend, and whilst in session, spoke willingly of her experiences. Lisa appears to have insight into the detrimental effects of her misuse of sleeping tablets and social isolation. However, Lisa’s precarious position at her work is of concern. Should she lose her job, Lisa may be at risk of increased depression, substance use and self-harm.

Perpetuating factors - what maintains the presenting problems

Lisa’s poor sleep patterns and low mood are perpetuated by rumination, her misuse of medication and her withdrawal from social situations. Lisa’s premorbid functioning was characterised by an active and social lifestyle and her current lack of activity is likely to be impacting on her mood and outlook. Lisa’s current difficulties at work also contribute to ongoing problems with mood and substance use.

Principles of treatment sequencing

In addition to developing a case formulation, there are a number of general principles about treatment sequencing that can help inform treatment planning. Consistent with the general principles of good mental health care, practitioners should focus on treating the disorder presenting most severely. Severity refers to the disorder that is most disabling and most likely to lead to risk of harm to the person or others. Practitioners should also focus on problems that are likely to impact on the veteran’s ability to engage in treatment. For example, problems that impair alertness, motivation, attention and emotional stability must be resolved before treatments that are dependent on these characteristics can begin. Suggestions for treatment sequencing for commonly co-existing mental health problems in veterans are outlined below.

Depression and high-risk alcohol use

When depression and high-risk alcohol use conditions are severe, treat the alcohol problems first, maintaining active monitoring of the risk of self-harm or suicide. This is because depression may have an organic basis associated with alcohol dependence, including delirium, impaired liver function or systemic illness. Treatment for depression without a reduction in alcohol use, will only have limited effectiveness. Depression may lift once the veteran is successfully treated for high-risk alcohol use. If both conditions are mild to moderate in severity, treatment can progress simultaneously.

Posttraumatic stress disorder and high-risk alcohol use

Treatment for PTSD and high-risk alcohol use can commence simultaneously, excluding the trauma-focussed component. The trauma-focussed component should not commence until the veteran has demonstrated a capacity to manage distress without resorting to alcohol. Once the veteran has reached this stage, practitioners can begin the trauma-focussed component of PTSD treatment.

Posttraumatic stress disorder, depression and high-risk alcohol use

Where conditions are severe, treat the alcohol use first, with active monitoring of the risk of self-harm or suicide. Initial phases of PTSD treatment, excluding trauma-focussed treatment, can commence simultaneously with the treatment of alcohol-use problems. Where all conditions are mild to moderate, simultaneous treatment can commence, excluding the trauma-focussed component of PTSD, until the veteran is able to tolerate two to three days per week without using alcohol.

Where PTSD, depression and panic disorder and/or generalised anxiety disorder (GAD) are severe, treat the depression first. This is because depression has been demonstrated to impair the effective treatment of anxiety disorders. If the conditions are mild to moderate, treat the PTSD first. This is because improvements in PTSD are likely to result in reductions in demoralisation and depression.

Where moderate to severe depression and panic disorder and/or GAD are present, focus on treating the depression first, ensuring you include breathing control to reduce panic. This is because depression is potentially life threatening, but also because there is evidence that poor morale and impaired attention will impair learning of arousal management, attention to exposure cues and compliance with self-care treatment.

Further Information

Complex Cases Assessment and Treatment: Provides further information, clinical tools and resources to assist health practioners in the assessment and treatment of comorbidity and case formulation in the veteran population.